2025 JPA Registration Form

Junior Police Academy Registration

2025 JULY 7th-11th
Student Name

First NameLast Name
Birth Date

MonthDayYear
Age
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number
Cell Phone Number
Please enter a valid phone number.
Mother's Name
Mother's Cell Phone Number
Father's Name
Father's Cell Phone Number
Name of School Enrolled
Highest Grade Completed
Name of Principal
School Phone Number
Briefly explain why you wish to be enrolled in the Glassboro Police Department Junior Police Academy.
List any associations, clubs, or organizations you belong to or are affiliated with.
Have you ever been arrested, convicted, and/or cited for any criminal offense?
Reference #1 Name
Relationship
Reference #1 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reference #1 Phone Number
Please enter a valid phone number.
Reference #2 Name
Relationship
Reference #2 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reference #2 Phone Number
Please enter a valid phone number.
Emergency Contact #1
Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Emergency Contact #2
Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
T-Shirt Size

YOUTH SmallYOUTH MediumYOUTH LargeYOUTH XLADULT SmallADULT MediumADULT LargeADULT XL
Short Size

YOUTH SmallYOUTH MediumYOUTH LargeYOUTH XLADULT SmallADULT MediumADULT LargeADULT XL
List any medications either prescribed or over the counter that you are currently taking. Describe the purpose the medications are prescribed.
List any allergies
I hereby certify that there are no willful misrepresentations, omissions, or falsifications in the foregoing statements and answers to the questions. I understand that any omissions or false statements on this application shall be sufficient cause for rejections of enrollment or dismissal from the Glassboro Police Department Junior Police Academy.

I further understand that the Glassboro Police Department will be conducting a thorough background investigation which may include, but not limited to, any criminal history and personal reference checks.

I hereby certify that the staff of the Glassboro Police Department to act for me according to their best judgement in any emergency requiring medical attention, and hereby waive and release the clinic from any and all liability for any injury or illness incurred while at the clinic. I have no knowledge of any physical impairment that would be affected by the above named person's participation in the academy.

I hereby certify the Glassboro Police Department to take photographs of my child and give them the ability to post them to their social media pages which include but are not limited to Facebook, Instagram, and their departmental website. Should I not want photographs of my child shared I will communicate this request to the Glassboro Police Department staff who will document said request.
DateTime
Email
example@example.com
Signature

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Junior Police Academy Registration